I’ve read that the stethoscope is being replaced in many practices by handheld Dopplers. Please say it isn’t so.
—Chagai Dubrawsky, MD, Houston
It isn’t so and will not be so, though your question does bring up the controversial issue of our increasing reliance on studies in lieu of physical examination. Why is this happening? For starters, there is mounting evidence that clinicians’ clinical exam skills are waning. A recent multicenter study compared cardiac examination skills in medical students, internal medicine and family practice residents and attendings, and cardiology fellows (Arch Intern Med. 2006;166:610-616). The researchers found that cardiac exam skills plateaued at the third year of medical school and did not improve thereafter, except in cardiology fellows, who scored the highest. Interestingly, the teaching faculty did not do significantly better than residents or students.
The demise of physical examination skills (combined with increased availability of technology, third-party reimbursement, and fear of litigation) has increased our reliance on imaging modalities to confirm diagnoses once based purely on physical examination. For example, I have seen portable ultrasounds (instead of landmarks) being used much more often in the placement of central venous catheters, and ultrasounds are guiding thoracenteses, even for sizable pleural effusions. It’s hard to argue with advances that reduce complication rates for our patients, although it does make me nostalgic for a clinician at my medical school who was rumored to be able to find a quarter placed in a grinder via percussion. So will the stethoscope be a vestige of the past? Of course not. Ultrasounds can’t detect lung pathology (beyond effusions), and even in evaluating the heart or a blood vessel, you need a stethoscope to at least detect a murmur or a bruit before investigating further by echocardiogram or an ultrasound.
—Susan Kashaf, MD, MPH (114-19)